Orbital follicular lymphoma with large cell component treated with low-dose radiotherapy: A case report and review of literature

A 77-year-old woman was referred for a one-eyed palpebral edema associated with diplopia. An orbit magnetic resonance imaging showed an orbital mass in the superior medial portion of the internal right orbit without any intraorbital involvement. Biopsies demonstrated a nodular lymphoma with mixed follicular grade 1-2 (60%) and large cell components. The tumor mass was treated with a low-dose radiation therapy (4Gy in 2 fractions) with a complete disappearance of diplopia within one week. At 2-year follow-up, patient was in complete remission. To the best of our knowledge, this is the first case of mixed component follicular and large components orbital lymphoma managed by first-intent low-dose radiation therapy.

Telomere shortening: a new prognostic factor for cardiovascular disease post-radiation exposure

Telomere length has been proposed as a marker of mitotic cell age and as a general index of human organism aging. Telomere shortening in peripheral blood lymphocytes has been linked to cardiovascular-related morbidity and mortality. The authors investigated the potential correlation of conventional risk factors, radiation dose and telomere shortening with the development of coronary artery disease (CAD) following radiation therapy in a large cohort of Hodgkin lymphoma (HL) patients. Multivariate analysis demonstrated that hypertension and telomere length were the only independent risk factors. This is the first study in a large cohort of patients that demonstrates significant telomere shortening in patients treated by radiation therapy who developed cardiovascular disease. Telomere length appears to be an independent prognostic factor that could help determine patients at high risk of developing CAD after exposure in order to implement early detection and prevention.

[Intensity-modulated radiotherapy and involved-node concept in patients with Hodgkin lymphoma: experience of the Gustave-Roussy Institute]

PURPOSE

To assess the clinical outcome of the involved-node radiotherapy concept with the use of intensity modulated radiotherapy (IMRT) in patients with localized supradiaphragmatic Hodgkin lymphoma.

PATIENTS AND METHODS

Patients with early-stage supradiaphragmatic Hodgkin lymphoma were treated with chemotherapy prior to irradiation. Radiation treatments were delivered using the involved-node radiotherapy (INRT) concept according to the EORTC guidelines. Intensity modulated radiotherapy was performed free-breathing.

RESULTS

Forty-seven patients with Hodgkin lymphoma (44 patients with primary Hodgkin lymphoma and three patients with recurrent disease) entered the study from January 2003 to December 2010. The median age was 31 years (range 17 to 62). Thirty patients had stage I-IIA, 14 had stage I-IIB disease and three had relapse. Forty-two patients received three to six cycles of adriamycin, bleomycin, vinblastine and dacarbazine (ABVD). The median radiation dose to patients was 36 Gy (range: 20-40). Protection of various organs at risk was satisfactory. The median follow-up was 57.4 months (range: 5.4-94.3). For patients with primary Hodgkin lymphoma, the 5-year survival and 5-year progression-free survival rates were 96% (95% confidence interval: 80-99) and 92% (95% confidence interval: 78-97), respectively. None of the three patients with recurrent disease has relapsed. Recurrences occurred in three patients: one was in-field relapse and two were visceral recurrences. Grade 3 acute lung toxicity (transient pneumonitis) occurred in one case.

CONCLUSION

Our results suggest that patients with localized Hodgkin lymphoma can be safely and efficiently treated using the involved node irradiation concept and intensity modulated irradiation.

JC human polyomavirus (JCV) and Epstein-Barr virus (EBV) replicative activities are detected in Hodgkin/Reed Sternberg cells (HRS) and circulating lymphocytes (PBL) of Hodgkin lymphoma (HL) and associated with relapse, especially in younger patients

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Background: The HRS derive from germinal-center B-cells, potential sites for latency and reactivation of JCV in immunosuppressed individuals. Replication of human polyomaviruses (JC, BK, SV40) and EBV was assessed in Hodgkin (HL) and B cell non-Hodgkin (B-NHL) lymphomas. Methods: FISH, immunohistochemistry for oncogenic proteins, PCR and DNA sequencing to identify polyomaviruses and EBV on involved nodes and in PBL before, during and after treatment (N = 73 HL, 91 B-NHL). Controls were 30 healthy donors, 70 solid tumors and 14 acute leukemia patients. Results: using FISH, JCV and EBV DNA were detected in all lymphoma nodes. High genome copy number of JCV and EBV were present in 60% and 63%, respectively, in HL patients versus 11% and 14% in B-NHL patients (P < 10−6; P < 10−5). Using nest-PCR, JCV DNA sequencing after laser capture microdissection identified the presence and specificity of JCV sequences in HRS. T antigen and LMP1 co-expression, in 34% of HRS, was associated with early HL relapse (P < 10−4), particularly in young patients (P < 10−5). Only in HL patients PBL, genome copy number of JCV increased significantly during treatment (42%). Rogue cells (cultured lymphocytes with multiple complex chromosomal aberrations indicative of genomic instability) appeared in 40% of patients, and correlated with relapse (p < 10−4). The same JCV sequences were found in tumor cells and PBL of HL patients. Co-genomic replication of EBV and JCV was highly correlated in lymph nodes and in PBL in HL. Conclusions: JCV genomic replication was detected for the first time in HRS, and associated to rogue cell emergence in PBL. Co-detections of JCV and EBV genomic replication in HRS and PBL are associated with relapse, especially in young patients. HRS and PBL JCV/EBV infections are linked and worth further studies.

No significant financial relationships to disclose.

Les traitements par les radiations ionisantes dans les lymphomes. Indications actuelles et futures

Presently, radiotherapy is rarely an upfront treatment in patients with lymphomas. The modern evolution of radiation treatment calls for the development of therapeutic niches in which radiotherapy remains absolutely necessary. The development of new imaging techniques and their use in radiation planning systems along with new sophisticated radiation delivery techniques such as IMRT and respiratory gating should permit an increased accuracy an increased accuracy in the treatment of tumor masses and a decrease in late normal tissue complications.

Baseline and treatment-induced chromosomal abnormalities in peripheral blood lymphocytes of Hodgkin's lymphoma patients

PURPOSE

To study chromosomal abnormalities in 49 patients with Hodgkin's lymphoma (HL), before and after treatment and at several times during a 2-year period.

METHODS AND MATERIALS

Simple chromosomal aberrations (CAs) and complex chromosomal rearrangements (CCRs) were counted in peripheral lymphocytes by painting of chromosomes 1, 3, and 4 (fluorescence in situ hybridization). A control population was composed of 20 healthy donors and 69 untreated cancer patients who had undergone various radiologic scans.

RESULTS

A greater frequency (p < 10(-4)) of spontaneous cytogenetic abnormalities was observed in untreated HL patients compared with the control populations. CCRs were observed exclusively in the HL population (p < 10(-4)). Chemotherapy was associated with a significant increase in the frequency of CAs (p < 10(-4)), according to the chemotherapy regimen (p = 0.002). Immediately after radiotherapy, a significant increase (p < 10(-4)) was observed in CAs according to the size of the irradiation field. Conversely, the significant increases in the frequency of CCRs observed after treatment did not correlate with the chemotherapy regimens, radiotherapy dose, or size of the irradiation field. The evolution of CAs vs. CCRs over time was also dissociated: during the follow-up of these patients, a significant decrease was observed in the frequency of CAs at 6 months and 1 and 2 years. In contrast, after an initial decrease for up to 6 months after treatment, the frequency of CCRs remained constant for up to 2 years.

CONCLUSION

Increased cytogenetic abnormalities were observed in untreated HL patients compared with the control populations. The greater frequency of cytogenetic abnormalities persisted in some patients. The presence of CCRs supports the concept of a unique genetic environment in HL patients that persists in response to potentially noxious treatments.

Premature chromosome condensation associated with fluorescence in situ hybridisation detects cytogenetic abnormalities after a CT scan: evaluaton of the low-dose effect

The purpose of this study was to assess the cytogenetic effects of the X ray irradiation used during a CT scan in order to estimate the mean absorbed dose in circulating lymphocytes. Chromosomal aberrations were scored in blood lymphocytes of ten patients undergoing CT scans, by applying fluorescence in situ hybridisation (FISH) to metaphase cells and premature chromosome condensation (PCC) with chromosomes 1, 3 and 4 painting probes immediately after exposure. This generated a dosimetric index that reflects the dose to the circulating lymphocytes. By using PCC a significant increase in the frequency of chromosomal fragment was observed immediately after a CT scan. However, no significant increase in chromosomal aberration was detected in metaphase cells. The mean dosimetric index immediately after exposure was 0.057 Gy (95% CI: 0.052-0.082 Gy). This dosimetric index depends essentially on the size of the examined and exposed blood volumes. This dose is in close agreement with the dose length product (DLP) (Gy cm) (R = 0.80). It should be kept in mind when justifying requests for diagnostic CT scan especially in young patients. The presence of chromosomal fragments after a CT scan indicated the cytogenetic effect of a low dose. PCC associated with chromosome painting is a method for detecting the cytogenetic effect of a low dose immediately after exposure.

A high and sustained response rate in refractory or relapsing low-grade lymphoma masses after low-dose radiation: analysis of predictive parameters of response to treatment

PURPOSE

To determine the efficacy of small doses of radiation in patients with recurrent or refractory low-grade lymphoma masses.

METHODS AND MATERIALS

Patients with refractory or relapsing low-grade lymphoma masses. The two largest diameters of the tumor mass were measured, whenever possible, before and after treatment. A dose of 4 Gy of radiotherapy was delivered to tumor sites in 2 fractions. Patients were evaluated for response 1-4 months later and at regular follow-up visits.

RESULTS

Forty-eight patients with low-grade lymphomas according to the working formulation received low-dose radiotherapy between March 1987 and November 1998. Most patients had advanced disease at the time of radiation treatment, and 80% had received at least two chemotherapy regimens before treatment. The median interval between the initial diagnosis and radiotherapy was 2.7 years (range 0-22 years). Low-dose radiation was delivered to 135 tumor sites. Nodal and extranodal tumor sites represented 80% and 20% of masses, respectively. An objective response was obtained in 81% of the sites, with 57% attaining a complete remission. The 2-year actuarial freedom from local progression (FFLP) rate was 56% (95% CI, 46-66%). Tumor masses </=5 cm in diameter had a significantly higher 2-year FFLP rate than larger masses (51% vs. 27%). It is noteworthy that the 2-year FFLP rate for patients treated with less than 2 chemotherapy regimens before radiotherapy was significantly higher than the 2-year FFLP rate for more heavily treated patients (96% vs. 48%). The 2-year FFLP rates for extranodal tumor sites and nodal sites were not significantly different. The tumor size (< or =5 cm vs. > 5 cm), the number of chemotherapy regimens (0-1 vs. more), and age at time of radiation treatment (< or =65 years or > 65 years) were significant predictive parameters of response to treatment.

CONCLUSIONS

In this retrospective study, low-dose radiation proved efficient, with long-lasting effects in the majority of patients with recurrent or refractory low-grade lymphomas. This simple and nontoxic treatment should be investigated prospectively in patients with advanced disease and a low tumor burden not immediately warranting chemotherapy.

Early locoregional high-dose radiotherapy is associated with long-term disease control in localized primary angiocentric lymphoma of the nose and nasopharynx

Nasal NK/T cell is a rare form of usually localized non-Hodgkin's lymphoma (NHL) which generally carries a poor prognosis when treated with conventional NHL chemotherapy protocols. We reviewed 20 consecutive localized stage I/II nasal NK/T cell lymphomas treated at our institution over a 29 year period. Median age was 44 (range 23-71). Front-line therapy was generally radiotherapy alone (35-70 Gy) before 1980 and combination chemotherapy after 1980. Six patients were treated with first-line radiotherapy and they achieved complete remission (CR). Two subsequently received combination chemotherapy. Five of those patients remained in complete remission, after 97+ to 277+ months. Twelve patients were treated with first-line chemotherapy including CHOP or CHOP-like regimen in seven cases, and COP in five cases. Only three of them achieved CR, five had partial response and four had progressive disease. Five of the seven patients treated with CHOP did not achieve complete remission. The nine patients who failed to achieve CR with chemotherapy subsequently received salvage radiotherapy but only two of them obtained CR. Finally, two patients were treated with alternated chemotherapy and radiotherapy and achieved CR, which persisted after 14+ and 26+ months. Median survival was not reached in patients who received front-line radiotherapy, and was 35 months in patients who received front-line chemotherapy. These findings confirm that chemotherapy gives a low complete remission rate in localized nasal NK/T cell lymphoma. By contrast, first-line radiotherapy seems to give favorable results, whereas its results are poorer when administered after resistance to chemotherapy. Whether the use of chemotherapy after radiotherapy, or alternated chemotherapy-radiotherapy regimens give better clinical results than radiotherapy alone will have to be evaluated prospectively in this type of NHL.

[Effects of ionizing radiation on the blood vessel wall]

PURPOSE

To study the biologic and clinical effects of ionizing radiation on blood vessels.

MATERIALS AND METHODS

Data extracted from experimental and clinical reports and articles.

RESULTS

Radiation-induced demise of endothelial cells is due to apoptosis. These cells are considered to be very radiosensitive. In vivo, however, the basal membrane might play a protective role. Early effects are characterized by swelling and shloughing of endothelial cells. Late effects are due to endothelial and smooth muscular cell proliferation. The underlying biologic mechanisms are little known. One hypothesis is the production of PDGF (platelet-derived growth factor) and FGF (fibroblast growth factor) by endothelial cells. Perivascular fibrosis might occur because of the TGF-beta production by endothelial cells and/or macrophages. Occurrence of late complications is probably multifactorial. Individual susceptibility to harmful effects of ionizing radiation, other vascular risk factors, and non optimal use of radiation treatment might contribute to the occurrence of late vascular complications. Modern radiotherapy using new techniques as the intensity modulation radiation therapy (IMRT) and the reduction of radiation doses and size of radiation fields should permit a dramatic reduction of vascular complications in cancer patients.

CONCLUSIONS

Ionizing radiation treatments can lead to serious late vascular complications. A better understanding of the underlying biologic processes and newer radiation techniques might lead to fewer late complications in the very near future.

Thallium-201 scintigraphy is not predictive of late cardiac complications in patients with Hodgkin's disease treated with mediastinal radiation

PURPOSE

To assess whether abnormalities depicted by Thallium-201 scintigraphy can predict the occurrence of late cardiac complications in patients with Hodgkin's disease treated with mantle field radiation therapy.

METHODS AND MATERIALS

Thallium scintigraphy was performed in 49 patients at a median of 75 months after initial treatment (range 28-208 months). Initial treatment consisted in chemotherapy, given to two-thirds of the patients and mantle field radiation, delivered to all patients, using a 25-MV linear accelerator. Myocardial perfusion defects were observed in 78% of patients on thallium scintigraphy. These patients had their cardiac status reassessed at a median follow-up of 13.5 years after treatment.

RESULTS

Forty-two patients were assessable, as data on the cardiac status were missing in 7 patients. The majority of patients received at least 40 Gy, and 75% of them were treated with one field per day. The median follow-up of patients is 13.5 years (range 9-24.5). Eleven cardiac complications were observed in 9 patients (coronary artery disease [n = 2], conduction-system abnormalities [n = 3], valvular defects [n = 5], and congestive heart disease [n = 1]). The median 15-year actuarial incidence of cardiac complications was 21% (95% confidence interval of 9-40%). The positive and negative predictive value of thallium scintigraphy was 19% and 77%, respectively. The univariate analysis showed that the extent of left ventricle exposure to irradiation was an adverse prognostic factor, and chemotherapy administered before mantle field irradiation was of borderline significance.

CONCLUSION

Thallium scintigraphy is not predictive of late cardiac complications. The extent of left ventricle exposure to radiation and possibly chemotherapy given before radiation treatment are adverse prognostic factors.

[Validation of biological dosimetry in patients conditioned with total body irradiation: conventional cytogenetics and in situ hybridization(FISH)]

PURPOSE

Validation of biological dosimetry versus physical dosimetry in malignant haemopathy patients conditioned by total body irradiation (TBI) before bone marrow transplantation (BMT).

PATIENTS AND METHODS

The scoring of chromosomal aberrations in peripheral lymphocytes irradiated in vivo was used to perform the biological dosimetry. The data were compared to those obtained with healthy volunteers' total blood exposed to in vitro irradiation with linear accelerator doses (0.2, 0.5, 0.75, 1, 2, 3, 4 and 5 Gy) for dose-response curves. In experimental animal models, can in vivo and in vitro responses be considered as being the same? All the published human data are based on retrospective dose evaluation with very large uncertainties on the dose precisely delivered to the subject. TBI before BMT was taken as a model where the dose calculation results from the physical method, with homogeneous beam and dose delivered precisely along the entire organism. In vivo response allows us to validate biological dosimetry in 15 adult patients (female + male), before (D = 0 Gy) and after the first fraction of 1.8 Gy, delivered by a linear accelerator (18 MV, dose-rate of 15.8 cGy/min-1). Two methods, conventional cytogenetics (CCG) and fluorescent in situ hybridization (FISH painting) of chromosome 4 were respectively used to analyze the unstable chromosome aberrations and stable chromosome aberrations.

RESULTS

Healthy volunteer lymphocytes, before irradiation, yielded 0.1% dicentrics and 0.3% translocations of chromosome 4, with 2.5% for the whole genome. Patients before irradiation had 2% dicentrics and 11.48% chromosome 4 translocations for the whole genome. In the 15 patients, for a physical dose of 1.8 Gy, the evaluated biological dose was 1.93 Gy (95% CI: 1.85-2.05 Gy) with conventional cytogenetics and 2.06 Gy (95% CI: 1.75-2.15 Gy) with FISH.

CONCLUSION

These results, in which the biologically estimated dose is in complete agreement with the dose calculated by physical dosimetry in the homogeneous irradiation model, suggest the validation of biological dosimetry in TBI conditioning.

Prospective randomized comparison of single-dose versus hyperfractionated total-body irradiation in patients with hematologic malignancies

PURPOSE

Fractionated total-body irradiation (HTBI) is considered to induce less toxicity to normal tissues and probably has the same efficacy as single-dose total-body irradiation (STBI) in patients with acute myeloid leukemia. We decided to determine whether this concept can be applied to a large number of patients with various hematologic malignancies using two dissimilar fractionation schedules.

PATIENTS AND METHODS

Between December 1986 and October 1994, 160 patients with various hematologic malignancies were randomized to receive either a 10-Gy dose of STBI or 14.85-Gy dose of HTBI.

RESULTS

One hundred forty-seven patients were assessable. The 8-year overall survival rate and cause-specific survival rate in the STBI group was 38% and 63.5%, respectively. Overall survival rate and cause-specific survival rate in the HTBI group was 45% and 77%, respectively. The incidence of interstitial pneumonitis was similar in both groups. However, the incidence of veno-occlusive disease (VOD) of the liver was significantly higher in the STBI group. In the multivariate analysis with overall survival as the end point, the female sex was an independent favorable prognostic factor. On the other hand, when cause-specific survival was considered as the end point, the multivariate analysis demonstrated that sex and TBI were independent prognostic factors.

CONCLUSION

The efficacy of HTBI is probably higher than that of STBI. Both regimens induce similar toxicity with the exception of VOD of the liver, the incidence of which is significantly more pronounced in the STBI group.

Gallium scan in the evaluation of post chemotherapy mediastinal residual masses of aggressive non-Hodgkin's lymphoma

Optimal evaluation of residual masses of non Hodgkin's lymphomas (NHL) after chemotherapy is of major importance, and gallium scan (GS) is routinely used for this purpose, particularly for mediastinal sites. However, sensitivity and specificity of GS in this setting has been diversely appreciated and needs to be more accurately defined especially if radiotherapy is not planned. A retrospective analysis selected all the patients treated in a single institution for aggressive NHL who presented a residual mass in the mediastinum after chemotherapy and who were evaluated by GS. The value of GS for distinguishing true complete responses (CR) from partial responses (PR) was analyzed in patients who were either submitted to resection of their residual mass or followed up without further treatment after GS. A residual mass with mean perpendicular diameters measuring 4.1 cm x 2.8 cm was found in 42 patients and was GS positive in 8 cases and negative in 34 cases. After GS, radiotherapy was delivered to 10 patients, but 12 patients underwent resection of their residual mass and 20 were followed up without further treatment. In the patients who did not receive radiotherapy, 3 false positive and 6 false negative GS results were disclosed. The specificity and the sensitivity of GS were 88% and 25%, and its positive predictive value and negative predictive value 40% and 78%, respectively. GS was not sufficiently reliable to evaluate post chemotherapy residual masses. Surgical resection of residual masses should be considered particularly in young patients. Patients in true CR should be spared pointless radiotherapy and its late side effects, while patients in PR may benefit from further intensified chemotherapy followed by radiotherapy.

Breast carcinoma in women previously treated for Hodgkin's disease: clinical and mammographic findings

The aim of this study was to describe the radiological characteristics of breast cancers occurring after treatment of Hodgkin's disease (HD). This study identified 23 women (age range 28-70 years, mean age 40 years) with 29 breast cancers (22 infiltrating carcinomas, 5 in situ, 1 sarcoma, 1 indeterminate) who had previously undergone mantle irradiation (35-40 Gy) for HD. Clinical and mammographic data were reviewed by two radiologists. Dosimetry was available for 16 patients. Time from treatment of HD to the occurrence of breast cancer ranged from 15 months to 35 years (mean 18 years); 79% were younger than 45 years and 76% of cancers occurred between 10 and 25 years of follow-up. The physical examination was positive in 76% and 6 patients had bilateral tumors (synchronous, n = 2; metachronous, n = 4). Eighty-three percent of mammograms (n = 24) were abnormal (microcalcifications, n = 72%; opacity, n = 54%; two inflammatory breast cancers). Seven cancers were only detected by mammography, but mammograms were normal in 4 patients. Breast cancer was located beyond or was overlapping radiation fields in 75% of cases. Starting 10 years after mantle irradiation of women with HD, the follow-up should include annual clinical breast examination and mammography.

[Esophagectomy for epidermoid cancer discovered during evaluation of ENT cancer]

The treatment of synchronous esophageal and head and neck carcinomas is difficult.

MATERIAL AND METHOD

Retrospective study of 33 patients treated with esophagectomy for an intrathoracic squamous cells carcinoma discovered during pan-endoscopy for a synchronous head and neck cancer.

RESULTS

In 7 cases (21%) it was advanced (pT3-4) esophageal cancers. The hospital mortality was 9%. Five year survival was 18% without stabilization of the survival curve, 60% of patients died of recurrence of tumor.

CONCLUSION

Esophagectomy is suitable for usT1-2 tumors if surgery is also indicated for the head and neck tumor. Radiochemotherapy is indicated for advanced usT3-4 esophageal tumors or when the treatment of the head and neck tumor is not surgery.

[Tumor radiosensitivity tests: state of assays in 1998]

Various assays measuring tumor radiosensitivity were developed in the early eighties. These assays were based on cell cultures derived from tumor biopsies. In most studies there was no correlation between measured radiosensitivity and treatment outcome. New assays using new techniques (such as measurement of radiation-induced apoptosis, or fluorescence in situ hybridization) have been developed recently. Preliminary results are encouraging, but correlation with treatment outcome is expected to be difficult to demonstrate as multivarious clinical and biological parameters are involved in loco-regional control.

[Pulmonary and cardiac late effects of ionizing radiations alone or combined with chemotherapy]

High doses of ionizing radiation (> 40 Gy) cause severe lung fibrosis in approximately 5% of the cases. There is a twofold increase when chemotherapy is added to ionizing radiation. Lung fibrosis is due to the destruction of lung tissue by ionizing radiation but also to various cytokine effects (PDGF-beta, TGF-beta). Only a minority of patients (approximately 10%) with abnormal X-rays will experience clinical symptoms. The most important radiobiological parameters which accounts for pulmonary tolerance is the fraction size. Irradiation of the heart begets multifarious late sequelae which are often left unrecognized. Chronic pericarditis affects approximately 5% of the patients when the irradiation dose exceeds 40 Gy. Coronary artery disease can be diagnosed in 5 to 10% of the patients. This late complication is more likely to occur if the patient was young at the time of the irradiation or if other risk factors are associated. Valvular defects can be found in 15 to 30% of the patients. However, the mortality rate is very low (0.5%). Finally, conduction defects can also be seen in approximately 5% of the patients. It is very likely that the radiation dose given to the heart should not exceed 30 Gy if late sequelae are to be avoided.

VIP (etoposide, ifosfamide and cisplatinum) as a salvage intensification program in relapsed or refractory Hodgkin's disease

Forty-two patients with refractory (15 patients) or relapsed (27 patients) Hodgkin's disease (HD) were included in a prospective single center study evaluating the efficacy of a regimen VIP combining etoposide 75 mg/m2/day days 1-5, ifosfamide 1.2 g/m2/day days 1-5 and cisplatinum 20 mg/m2/day days 1-5, one course every 4 weeks as salvage therapy in patients with refractory or relapsed Hodgkin's disease, potentially eligible for high-dose chemotherapy with reinjection of hematopoietic stem cells (HSC). If patients were considered chemosensitive after two courses of VIP, high-dose chemotherapy followed by the reinjection of HSC was planned. After two courses of VIP, 67% achieved an objective response including 38% complete responses. Overall, 28 patients went on to high-dose therapy with reinjection of HSC, and 46% of grafted patients are in a sustained complete remission. When the overall patient population is considered, 33% are in complete remission (CR) with a median follow-up of 37 months. A CR of less than 12 months and refractory disease were associated with a poor survival. These results showed that the VIP regimen is effective in relapsed or refractory HD and allows high-dose therapy to be given in the case of most responding patients. However, results in patients with refractory disease or a first complete remission of less than 12 months need to be further improved.